Early child development: Report on case studies

EARLY CHILD DEVELOPMENT:
Report on case studies
Joana Morrison, Peter Goldblatt, Hynek Pikhart & Milagros Ruiz

Authors:
Joana Morrison, Peter Goldblatt, Hynek Pikhart & Milagros Ruiz
Acknowledgements:
Sabine Haas, Gesundheit Österreich, Austria; Jana Hainsworth, Eurochild, Belgium; Maria
Herczog, Family Child Youth Association, Hungary; Sharon Lyons, Early Years, Northern
Ireland; Marion Macleod, Children in Scotland, Scotland; Eva Flora Varga, Family Child
Youth Association, Hungary; Maria Roth, Cluj University, Romania; Marion Weigl,
Gesundheit Österreich, Austria; Pauline Welmsley, Early Years, Northern Ireland.
Published as part of the DRIVERS project by:
Research Department of Epidemiology and Public Health
University College London
1-19 Torrington Place
London WC1E 6BT
UK
Tel: +44-20-7679-1906
Correspondence: h.pikhart@ucl.ac.uk
Suggested reference:
Morrison J, Goldblatt P, Pikhart H, Ruiz M. Early child development: Report on case
studies. Report produced as part of the ‘DRIVERS for Health Equity’ project. Research
Department of Epidemiology and Public Health, University College London. London:
2015. Available from: http://health-gradient.eu/.
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Table of Contents
Introduction........................................................................................................................... 2
Case study methodology....................................................................................................... 4
Results................................................................................................................................ 10
Toybox ............................................................................................................................ 10
Netzwerk Familie............................................................................................................. 13
Sure Start Hungary.......................................................................................................... 17
Universal Health Visitor System....................................................................................... 21
Theotokos Centre............................................................................................................ 24
Discussion .......................................................................................................................... 29
CONCLUSIONS AND RECOMMENDATIONS.................................................................... 34
REFERENCES ................................................................................................................... 36
ANNEXES........................................................................................................................... 39

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Introduction
The objective of case studies in areas that are key drivers of health inequities is to identify
services, policies or practices that are already in place that have the potential to reduce
inequalities in health and its social determinants. The early years case studies described in
this report relate to one of the three key areas - early childhood development - covered by
the DRIVERS project – The other areas being employment and working conditions and
income, welfare and social protection. Case studies were also conducted on advocacy for
health equity. To achieve the objective described above, five early years case studies were
selected from a longer list of proposals - using the methodology described below- and in-
depth investigations were carried out to identify the efficacy, reach and possible
transferability and scalability of the interventions represented by the studies. To do this,
explanations were developed of what works for which groups of people in what situations.
The methodologies used to achieve this are also described below.
The DRIVERS Project [2012-2014] – a three-year research project funded by the European
Union 7th Framework Programme-focuses on three of the key drivers to reduce health
inequities: early childhood development, fair employment and working conditions, and
welfare, income and social protection. It assesses the impact of policies and programmes, to
develop new methods and evidence, and provide policy recommendations and advocacy
guidance to reduce health inequalities within Europe (1).
Early years interventions that are designed to reduce inequalities in health and development
and their social determinants must focus on actions which give all children the best start in
life and are delivered with an intensity proportionate to the social needs of the children and
their families (2-4). The Driver´s ECD case studies were selected so as to represent a range
of services that, on paper, appeared to have the potential to be rolled out in this way.
Ensuring the best start in life for children can be achieved by improving outcomes in the
different domains of early child development -cognitive, communication and language, social
and emotional and physical (5-7). The interventions may be aimed at children, their parents
or both. The objective of this study was to identify, describe and explore interventions,
services and programmes was aimed at ensuring the best start for children by reducing
inequalities in health and development and their social determinants (8-11). Those case
studies reviewed were proposed and implemented by third parties: not-for-profit
organisations, agencies and statutory bodies working to promote health and equity. These
form part of the Eurochild and EuroHealthNet networks and they collected and analysed the
data in collaboration with work package leaders (1).

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Key questions
 Is there evidence that the case studies delivered improvements in the domains of
child development that could contribute to subsequent reductions in inequalities in
health?
 How do the services investigated deliver improvements in child development in the
early years?
 Do the services provided reach all of their target groups? Are these the children and
families who would benefit most?
 Could the interventions be transferred to other countries and be effective with
comparable target groups?
 Could they be rolled out with sufficient scale and intensity to impact on the magnitude
of health inequalities?

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Case study methodology
Methodological development
We carried out a descriptive and exploratory qualitative study to capture early years
programmes’ staff and users’ unique accounts of reality in order to report their knowledge on
inequalities in ECD and health. Data was collected from five countries: Austria, Hungary,
Northern Ireland, Romania and Scotland participating in the Drivers project as third parties.
Characteristics of the participating interventions and methods of their selection
Eurochild and EuroHealthNet’s third parties responded to questionnaires designed by UCL
which collected extensive information on the following ten interventions: 1) Family Network,
a targeted referral service in Austria, 2) Prolepsis, a Programme on food aid and promotion
of healthy nutrition in Greece, 3) Sure Start, Hungary, 4) a mother-baby unit for teenage
mothers in Hungary, 5) the universal health visitor service in Hungary, 6) Eager and Able to
Learn in Northern Ireland, 7) Toybox in Northern Ireland, 8) the Iris maternal centre in
Romania, 9) the Theotokos mother and child centre in Romania, 10) The Mother´s Club in
Romania. Information was also provided on Growing Up in Scotland (GUS), a longitudinal
cohort study in Scotland.
The following selection criteria were then applied to choose the interventions to provide a
balanced mix of projects and country representation:
 Country coverage: ensure the selected interventions encompass sufficient range of
countries to reflect the different contexts in Europe.
 Aimed at children before they enter school: the target group is aged 0 to the start
of primary schooling.
 Potential to reduce inequalities: actions taken are credible ways of addressing
inequalities in health and development and their determinants.
 Addresses developmental domains: interventions need to address at least one
domain of child development. Targeting more than one is desirable but not essential.
 Parenting: it is desirable that, by helping with parenting skills and or financial or
other support needed for daily living, interventions contribute to creating the
conditions for improving nurturing and healthy development.
 Evaluation: the intervention has undergone an evaluation or there is a prospect of
carrying it out in the time available.
Based on these criteria, the interventions described below were selected:
1. The Family Network in Austria: a targeted referral service aimed at families in need,
with children aged 0-2.
2. Sure Start and the Universal Medical Visitor service from Hungary in order to combine
assessing the transferability of an intervention designed in a different country/context
and a universal intervention.
3. Toybox from Northern Ireland. An intervention aimed at reaching out to Traveller
families to enhance the social, educational, emotional, physical, language and cognitive
development of children.
4. The Theotokos Centre from Romania is aimed at providing unemployed and Roma
single mothers and their children with child-care support and programmed activities such
as parenting advice.

5
5. Separate discussions were held with Children in Scotland to identify interventions in
Scotland, as a result of which the following three interventions were selected: The
Lickety Leap theatre production consisting of drama, storytelling and improvisation
supporting children’s cognitive development and personal efficacy; the Ruchazie Family
Centre delivering integrated early childhood education and care and outreach support to
families in deprived areas; and the North Ayrshire early years service for two year olds
providing support for parents and positive learning experiences for children in pre-school
education.
Brief description of the selected interventions
Toybox, Northern Ireland
Toybox, in partnership with parents and children was set up in 2003 across Northern Ireland
to provide rights based outreach play services to Traveller families with children aged 0-4
years. Its aims are to enhance the social, educational, emotional, physical, language and
cognitive development of children as well as strengthen the capacity of Traveller parents to
support their children’s well-being and eagerness to learn. Families involved in the project
live in deprived areas in Northern Ireland.
Through weekly home visits by Project Workers, parents with their children, engage in the
High Scope (12) method of play which supports, challenges and stimulates the children’s
interest in learning and prepares them for education. At present a team of 10 Project
Workers deliver this programme to over 220 families and 317 children across Northern
Ireland.
Netzwerk Familie, Austria
The Netzwerk Familie (NF) programme was developed and tested during the years 2009-
2010 as one of three pilot programmes implemented based on a call for early child
interventions published by the regional government. NF is an institutional co-operation of the
social services of Vorarlberg and the provincial specialist’s association of paediatricians. On
the basis of the evaluation it was selected for the roll out throughout the whole province of
Vorarlberg, which started in 2010. In the year 2014 it was selected as a model project for the
implementation of early childhood networks in all nine Austrian provinces. The general
objective of NF is to reduce health inequality by supporting early child development among
families in need. It systematically identifies families of children aged 0-3 in need with the help
of the social and health system, ensuring they receive specific support and counseling. They
also accompany them during specific periods when required.
Sure Start, Hungary
The Sure Start program is provided to families with children 0-5. Sure Start premises, called
“houses” in Hungary provide mothers - or other caregivers - and their children planned
activities delivered by trained staff. The program aims to reach families from diverse
backgrounds to promote mutual learning and support as well as integration of deprived
and/or minority- mostly Roma-children and their parents into the community. The program is
delivered in the 36 most deprived sub-regions in Hungary. There are very limited day care
opportunities for children under 3 and many of them start kindergarten at age 5–the
compulsory starting age. Sure Start Hungary is aimed at reaching children during the early

6
years and strengthening parenting capacities, also providing advice and support to women
to seek employment.
Universal health visitation system, Hungary
Health visits delivered at home for expecting mothers and children. The programme has
universal coverage and its aims are to give advice on infant care and children, prevent
unwanted pregnancies, detect child abuse and maternal depression. Funding is provided by
the central government.
Theotokos Centre
The aim of the Theotokos Centre is to offer child-care support to single mothers and families
in difficult situation, preventing mother-child relation disruptions and child abandonment. The
target group are mothers who lack social or/and financial support in raising their children. In
terms of ethnicity, the majority of mothers are ethnic Roma (60%), the rest being Romanian
or Hungarian, their ages are between 14 and 25 years and they are mostly unemployed. The
initiative has several components addressed to mothers and their children, mainly full day
care services for children aged 0 to 2 years, but also counselling, information services and
health-care services for parents, especially single or disadvantaged mothers. As specific
objectives, the centre aims to ground the mother-child relationship on a solid parenting skills
background, and also give children a healthy and skilful early development.
Lickety Leap, the Ruchazie Family Centre and the North Ayrshire early years service,
Scotland
The Licketyspit Theatre Company, focusing on its LicketyLeap production, used drama,
storytelling and improvisation to support children’s cognitive development and personal
efficacy in disadvantaged communities and engaged their parents in sustaining the effects of
the intervention. The Ruchazie Family Centre provided a wide range of support, advice and
information services for local families in East Glasgow. It was staffed by a multi-disciplinary
team and provided integrated early childhood education and care, outreach support for
parents and direct work with families and children. It was delivered and planned in a flexible
way responding to the needs of recipients. The centre was accessible to any family in the
community and accepted referrals from other services therefore providing a universal
service. It encouraged mutual support among families and developed a sense of cohesion in
the community. Emotional support was provided in a safe environment by qualified staff. The
North Ayrshire Council piloted the inclusion of at-risk two year olds in their pre-school
education provision, normally available to three and four year olds. The programme included
provision of a wide range of age appropriate play equipment, parent groups and individual
parent support.

7
Socioeconomic profile of the intervention areas
Indicator UK Austria Hungary Romania
Year of the
indicator
Percent of population
aged 0 – 15 years
17.6 14.4 14.5 15.5 2013
Percent of employed
population aged 15-64
years who are women
45.1 46.1 45.6 42.4 2013
Unemployment rate (%) 5.1 5 10.3 7.6 2013
Percent of children aged
under 18 in poverty
9.8 8.2 9.4 24.9 2010
Percent of children aged
0-5 years living in
overcrowded conditions
29 44 80 71.31
2010
Public spending on
family services as a
percentage of GDP
1.38 0.57 1.16 2.2 2009
Children aged 0-3 years
in formal child care
73 87 92 85 2012
Notes
1
For Romania, the indicator is percent of children aged under 18 years living in overcrowded
conditions
Sources: International Labour Organization (14), Organisation for Economic Co-operation
and Development (15) and the European Commission (16).
Study sample
Third parties identified and interviewed 25 parents, programme managers and key
professionals -from within the selected interventions- for in-depth, semi structured interviews.
They also liaised with the programme managers to identify potentially ideal staff and parents
-also involved in the interventions- for the focus groups. A final sample of 46 respondents
participated. The participants and number of interviews for each case study are detailed
below. This methodology was not used in Scotland.
Toybox
• Ten parents/carers interviewed at home
• One focus group with 10 staff
Netzwerk Familie
• Two interviews with the heads of NF at their premises
• One interview with the person responsible for child and youth welfare in the
provincial government at the premises of the provincial government in
Bregenz
• One interview with the chairman of the provincial specialists association of
paediatricians in Vienna
• One focus group with 11 cooperation partners
• One group interview with 4 mothers/fathers

8
Sure Start Hungary
• One interview with the expert who adapted the service to Hungary
• One interview with a Sure Start program manager in Budapest
• One focus group with 8 mothers attending Sure Start centres
• One focus group with 8 mothers benefitting from Sure Start and the universal
health visitor programme
Universal health visitor programme
• One interview with a health visitor from a rural area
• One interview with a health visitor from the suburbs of Budapest
• One interview with a supervisor of health visitors in Budapest
Theotokos centre
• Four individual interviews with women who had attended the centre
• Two individual interviews with staff working at the centre
• One focus group with four mothers attending the centre
Data collection
ECD quantitative data collection
Third parties collected quantitative data available in relevant reports or other documents
such as written records or official statistics to compliment the data already provided in the
first template.
ECD qualitative data collection
Qualitative methods were used to provide non-quantitative data such as user’s or
professionals’ knowledge, perceptions and beliefs (13). Third parties used the following
qualitative methods in this study: individual in-depth interviews and group interviews; namely
focus groups and followed the criteria for reporting qualitative research suggested by Tong
and colleagues (17), where appropriate. A description of the methodological development
and data collection is provided below.
Individual in-depth interviews
Third parties identified and interviewed 25 parents, programme managers and key
professionals in total for selected interventions and collected information on the
aforementioned key questions, following the interview guide provided below in Annex 4. The
guide described the issues or questions to be explored. It was developed based on the key
questions and the objectives as described in the Description of Work (DOW).
Third parties carried out the interviews lasting at least one hour in their native language.
They provided a comprehensive summary of the interviews translated to English to lead
partners. Interviews were the preferred method for hard to reach groups or high level
managers, for example.

9
Focus groups
Third parties liaised with the programme managers to identify a potential group of ideal
participants for the focus groups.
Group interviews were used as a method for data collection as they provide valuable and
rich information due to the dynamics of group discussion (13, 18). Furthermore, the
interactions and influences taking place provide in-depth information. It may also help to
reflect the everyday reality by reproducing a real life environment and its social interactions
(14).
Each focus group had approximately 6-10 participants, with similar socio-economic
backgrounds, age and occupation and lasted approximately 1,45 hours. There were 46
participants in total. The moderator guided the discussion partially, following the discussion
topic guide provided, developed with the same criteria as the interview guide. The narrator
took notes and recorded the sessions. Staff had the opportunity to ask any questions before
we commenced however, no questions were asked. At the end of the session the narrator
offered a short summary of the issues discussed so participants could add or rectify
information.
Ethical considerations
Informed written and verbal consent was obtained from all the participants for taking notes or
recording the sessions. The information was anonymised and confidential. Participants from
the Netzwerk Familie case studies received a small payment.

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Results
The information obtained from the interviews and focus groups is described below for each
intervention. This includes respondent’s perceptions of the intervention. For each
intervention the information is organised according to headings that emerged from each of
the case studies, based on the structure listed in the interview guide (Figure 1).
Toybox
A. Interviews with parents and/or carers
Socioeconomic context of the area and users receiving the service
There was a mixed response when describing the socioeconomic background of the area
where Toybox is delivered. The main issues identified by respondents were unemployment;
social housing, racism, benefits and a nice area to live. Most parents described
unemployment as an important issue and while many parents liked where they lived, there
were little or no amenities for their children.
Intervention delivered and objectives
It was generally agreed by all interviewed parents that Toybox consists of learning through
play with their child/ren. Some of the activities identified were; reading, jigsaws, outdoor play,
making cards, singing and building. Eight of the ten parents said Toybox was delivered to
their family at their home.
Providing support for parents
Parents mentioned additional activities related to the service including workshops, help with
making appointments for other services and transition support.
Domains of development
All parents agreed that the project impacted positively on their child’s development. Parents
identified improvements in development in several of their children’s skills. One parent
explained that health workers had remarked upon improvements in their children’s
vocabulary. Another explained that Toybox had helped in their children’s development
because staff from the programme helped them get into SureStart. Other responses listed
aquiring skills such as reading.
“JC has become a lot more sure of himself”; “It’s helped with their speech and they
play better together.” Toybox parents.
Methods use to reach beneficiaries
Principal contact methods were other family members, health visitors and project workers
providing home visits, the later identified as the most common. Five parents described other
services delivered to them such as: SureStart, After School, Play Club and Safe and Well
programmes.
Information on evaluations conducted
Three parents personally acknowledged the work of Toybox by saying how much they
enjoyed the programme. They also referred to strong, positive and relaxing relationships
established with their child and staff worker.

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Barriers and enablers
Parents explained that finding childcare when they had courses to attend was sometimes a
problem. Also, some mothers did not feel comfortable if men participated in the courses
delivered in community areas. The culture of travelling was also identified as a potential
barrier in addition to feuds, weddings and funerals. Positive enablers however, were also
identified by parents, these included trust and confidence in the staff delivering the project.
B: Focus group with Toybox staff
There were many points of agreement among staff when describing the social and economic
backgrounds of the main users of the intervention; lack of jobs, families living in social
housing, single parents, parents with low education, drugs, alcohol abuse and large families
which were often unstructured.
“…inherited class system, dysfunctional families, lack of jobs and a lot of barriers.”
Toybox staff
The activities carried out within Toybox were aimed at enhancing the global development of
Traveller children ages 0-4. Informants also explained that a further objective was
strengthening parents’ capacity to assist in their children’s learning and development by
supporting and empowering parents to develop their own educational skills. The
respondents referred to other aims such as encouraging and supporting parents/families to
become involved in community activities, promoting and supporting the recognition and
representation of Traveller culture in all areas of work and policy.
“It has improved the confidence and relationships between Toybox workers and
Traveller parents’ by bringing the project into the homes of Travellers”. Toybox staff
The programme was described by respondents as being mostly in families’ homes.
Addressing potential inequalities in early child development
The staff interviewed felt that Toybox was able to establish a link between parents and
health care services as they assisted parents-during Toybox visits-in managing forthcoming
appointments and accompanied them. Community events delivered by Toybox ensured that
families had access to relevant health information regarding smoking, nutrition and road
safety. Some staff gave personal accounts of the impact these events had including families
working closer with other services, mothers considering joining new groups such as breast
feeding groups and parents hearing about and receiving vouchers they were entitled to.
Also, staff explained that participants had access to fresh fruit in Toybox play sessions which
increased their opportunity to taste, smell and eat new types of fruit.
“Dads were happiest when engaging in construction like play.” Toybox staff
The staff described the High Scope-based practice during the play session and the child
observation record booklets which helped them identify needs and highlight children’s
achievements.

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Providing support for families
Staff felt that the trusting relationship they had built with parents was very important for
children’s health and development and this was achieved by staff members visiting the same
family’s home for months and sometimes years.
“The acceptance by families of the service is very important and we have Toybox
now visiting different generations of the same family.” Toybox staff
One staff member spoke in detail about the wealth of knowledge families have. All staff
agreed that parents are important people in their child’s lives and another staff member said
that the level of support each family received from tem varied.
“Ask parents for advice…it is not about doing onto parents …” Toybox staff.
“Told Mum: you’re such an important person in your child’s life. The parent began to
cry when I said this.” Toybox staff.
Programmes such as the “cook it programme”, for example, were attended to by many
parents according to staff. One member felt that parents were satisfied with the content of
the programme. Parents shared healthier foods they had learnt to prepare. Staff noted that
their role was to support the family only and it was important that this play continued after the
project worker left the home.
It was strongly agreed by the interviewees that child development improved with Toybox.
Staff felt Toybox included social, emotional, physical, creative and intellectual areas of child
development. Their play sessions were planned carefully taking the child’s interests and
abilities into account and suitable resources selected.
Staff explained that in order to support children’s development the engagement of parent/s in
play was very important as there is a prominent role for them. Staff noted that their role was
to provide families with support but it was important that play continued after the project
worker left the home. They also discussed learning outcomes with parent/s.
Methods used to reach beneficiaries
The interviewed staff members explained that Traveller families with children aged 0-4 years
living throughout Northern Ireland were the principal beneficiaries. Other people also
included in the programme were extended family members living in or near beneficiaries’
homes.
Staff described that they initially identified and reached families through various methods;
when the project began in 2003 support groups were vital and necessary to identify and
reach families. They also listed other services today which are vital in collaborating with and
in identifying new families including: practitioners, health visitors, the Public Health Agency,
Safe and Well, Barnardos, schools and SureStart. Some Traveller families were self-
referred, however, staff felt this was a small number. In some cases, family members
identified participants who could be registered on the project.
“Toybox has been a very successful project in engaging Traveller families and
supporting the development of Traveller children through play. It is recognised as a
successful model in child development especially among disadvantaged groups.”
Toybox staff

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The staff listed on-going evaluations of the project such as yearly surveys, questionnaires
and participative evaluations carried out among parents, Sure Start and Early Years internal
staff. There was an external evaluation completed in 2007 and three staff summarised his
evaluation outcome as a successful model in child development especially among
disadvantaged groups. It was also considered to be important in filling the gap between
families and other services.
“It has been very successful at filling the gap between families and other services. It
has removed barriers to Traveller children entering education.”
Barriers or enablers
There was general agreement by staff that there was none or little support or advice for
families with children over 4 years of age. Staff expressed the view that families needed this
support especially in rural areas and it wasn’t available. They felt appointments were missed
because of this. Participants also felt that transitioning into school was an issue due to lack
of help and support offered by schools and after-schools.
“Families struggle getting doctor’s appointment.” Toybox staff
Staff agreed they sometimes had problems with other service providers. A range of positive
enablers for the implementation of the project were also identified, staff agreed that access
to good resources and quality training effectively supported them in their work. The internal
knowledge, expertise and experience within the team were identified by one of the newest
staff members.
“Services in my area felt Toybox was stepping on their toes and taking over their good work.”
Toybox staff
Netzwerk Familie
A: Individual interviews with managers
The participants explained that Netzwerk Familie reaches approximately 5% of all families
with children under the age of 3 who need support. These range from high income families
with multiple or premature birth to socioeconomic disadvantaged ones. According to
respondents, it was easier to reach families with financial constraints or migrants than young
pregnant women described as not fitting into the model of mainstream intervention users,
for example women from a high socioeconomic position with postpartum depression.
According to the respondents’ experience there were some knowledge gaps among
cooperation and network partners regarding early child development in Vorarlberg,
especially interventions to support bonding between parents and their children. Netzwerk
Familie’s objectives were to fill these gaps by providing training and organising events with
experts.
It is aimed at families who encounter barriers in accessing existing programs. It builds a
continuous relationship with the family which is the program’s main success factor. They

14
also explained that there is no knowledge on how many and why some families refuse the
referral.
Respondents explained that the programme aimed to cooperate with the health and social
sector, however cooperation with some professions was considered difficult-for example with
medical doctors. In the recent years other groups such as child care institutions or local
government officials were becoming increasingly involved.
Addressing potential inequalities in early child development
The respondents explained that Netzwerk Familie helps families in need until the child is
three years old. Families are faced with various issues; financial difficulties, violence, social
isolation or challenges associated with parenting and caring for their children in addition to
children’s health problems such as multiple or premature births.
Regarding the activities carried out, the participants described a resource developed within
Netzwerk Familie which is orientated towards families in need. It coordinates interventions
for families in a systematic and structured way involving all relevant partners.
Netzwerk Familie staff members felt that the family climate improved after receiving support.
They described observing improvements in how families deal with their children and partners
which, in turn, has positive effects on the early development of children. These
improvements were also reported by the families receiving Netzwerk Familie services. The
staff interviewed explained that a thorough evaluation should be carried out as there is no
data in Vorarlberg to show that Netzwerk Familie has a positive impact on child and youth
welfare.
Staff explained the different conditions for implementing early childhood intervention
programs in rural and urban areas which should be considered in program planning. It is
challenging to involve local physicians as they need incentives in order to cooperate.
Netzwerk Familie was introduced as a result of winning a tender which has impeded
cooperation in the long term between different partners who competed for it. They described
the need for high-level political leadership. They also remarked upon the challenges in
reaching young pregnant women or mothers which do not fit into the model of mainstream
intervention users such as those from high socioeconomic positions with postpartum
depression. Also, in the rural areas receiving benefits from the programme is stigmatising.
B: Focus group with Netzwerk Familie parents
The parents explained that Netzwerk Familie offered support when mothers left the hospital
and continued maintaining contact and offering consultation. The continuity of contact and
consultation was experienced as helpful by mothers.

15
One of the parents described being filmed by a Netzwerk Familie professional while taking
care of her child at home. They later analysed the video and the Netzwerk Familie
professional explained what could be improved. This activity was seen as very helpful by the
mother and she considered it had a positive impact on families.
Addressing potential inequalities in early child development and health
Parents explained how family members’ relationships improved after Netzwerk Familie visits
and daily life in the family atmosphere became more relaxed. Mothers felt more self-
confident and structured in their life during and after participating in the Netzwerk Familie
programme.
Methods used to contact beneficiaries
The parents described how they were referred to the programme. After having given birth,
one parent described being approached at the hospital by a parents counselling programme,
other parents explained that health care professionals and health care services that are
aware of the programme referred them and one was self-referred.
Respondents explained that activities which included fathers had lower attendance than
other activities. They also felt that the first contact should not take place immediately after
the birth of the child as this was too stressful for mothers. Lack of further service offer after
the child´s third birthday was also seen as a barrier.
C: Focus group with Netzwerk Familie staff and cooperation partners within the
network
Netzwerk Familie staff and cooperation partners within the network made reference to a lack
of programmes for mentally ill mothers, post-partum depressions and mother-child-
treatments in health clinics (such as those in Germany) in Vorarlberg. They also referred to a
shortage of programmes and group interventions for pregnant women. Specific programmes
aimed at women with language barriers were also described as important.
The participants referred to the lack of programmes for pregnant and post natal mothers;
Netzwerk Familie has the objective of filling this gap. It does so by prioritising the problems a
family might be experiencing and finds the right intervention to solve it. Sometimes the
problem is hard to identify if there are multiple factors causing stress, in this case Netzwerk
Familie was perceived by the interviewees as an improvement of the social services
delivered. The work of Netzwerk Familie was described as facilitating the physician’s work
by assuring that the families were taken care of and obtaining the most appropriate help for
problems outside the medical sector. The round tables and other events enabled
cooperation between the partners and Netzwerk Familie.

16
The work of Netzwerk Familie had a positive impact on the families, according to Netzwerk
Familie staff and cooperation partners within the network. It was observed by staff that family
members dealt better with each other and daily life in the family became more relaxed after
the intervention. Another outcome was that women became more self-confident and
structured in their life during or after participating in the programme.
It was considered important by staff for Netzwerk Familie to prioritise the family’s problems
and find the right intervention to solve it. A challenge for Netzwerk Familie staff and
cooperation partners within the network was to establish a relationship with the accompanied
families and at the same time to refer them to other intervention programmes. Sometimes
there are multiple factors that stress a family and they need to be referred to various
intervention programmes. In these cases Netzwerk Familie was seen as an enrichment of
the social services system.
Respondents were of the opinion that Netzwerk Familie reached their target group in
general. However, some families were not reached.
Some Netzwerk Familie staff and cooperation partners within the network reported
experiences which - from their point of view - show that some families are afraid that
Netzwerk Familie might cooperate with the child and youth welfare service. This was
assumed when they read the information flyer about the intervention programme where the
provincial government is listed as a funding source. The main reason families did not accept
support offered by Netzwerk Familie – according to the cooperation partners- was due to the
local attitude (need to cope with situation themselves) and the negative image of “getting
help”. They explained that parents feared being reported to social services. The increasing
number of ambulant births was also pointed out as a barrier to reaching families as these are
harder to identify or approach.
Respondents expressed that there should be no competition between services. Networking
with the relevant institutions of the health and social sector was considered important.
According to respondents, regional politicians need to share the principles and understand
the importance of a programme like Netzwerk Familie. If there are existing institutions or
structures in a region then these should be used and strengthened. Staff also explained that
it was difficult to collaborate across disciplines in the medical sector, especially during the
transition from pregnancy to birth and through to childhood. The staff explained that it is
useful to have a multi-professional team that works with the families within the programme.

17
Sure Start Hungary
A: Individual interviews with managers
The interviewed staff explained that the Hungarian adapatation of Sure Start was develepod
in order to support children and their families to reduce health and social inequalities in the
most deprived micro-regions in the country. The local social and child welfare services were
described as over burdened, under-resourced and often not able to provide the necessary
support.
“Budapest the House provides services in the most disadvantaged district with a high
ratio of Roma and immigrant, primarily Chinese population…The local social and child
welfare services are overloaded, under resourced and often not able providing the
necessary support.” Sure Start manager
Interviewees described the structure of the programme which included an intensive 360
hour-long training program with four aims: to ensure the optimal development of the child; to
establish a good relationship with the parents; strengthening cooperation between the local
community and fostering good relationships between professionals.
“We had four aims: to ensure the optimal development of the child; establish a good
relationship with the parents; strengthen the cooperation between the local community
Sure Start manageras well as between professionals.”
With reference to the staff involved in delivering the programme, interviewees responded
that every Sure Start centre has three permanent employees: the program director which
usually holds a degree or diploma in a related field, experienced special education teachers,
kindergarten teachers and health visitors or social workers. At least two employees have
completed secondary education. There is no minimum level of education set for the third
employee who is usually recruited from the local community. They are the principal
connection between the centre and the communities. There are also some volunteers
carrying out different responsibilities on a temporary basis.
Books and toys are available for children and they can spend time with their parents.
Professional assistance is also provided if needed. The respondents explained that
parenting classes are available as well as self help groups and personal consultations.
Parents may seek work with provided assistance and use the IT services. The programme
mainly addresses the child’s complex needs through play by encouraging the will and
aptitude for discovery. Staff also explained providing parents with consults, encouraging
interaction and reflection on the needs of children. The staff respondents described
organising activities to encourage and promote physical development, communication and
emotional stimulation, independency, attention, memory, major motor skills and sense of
direction.
“Parenting knowledge should be provided to the families, e.g. information on the
developmental needs of the child and the appropriate ways to respond to these
needs must be learnt just like non-violent communication, disciplining, listening to
children and taking their views into consideration.” Sure Start manager

18
The location of Sure Start centres is decided upon by placing these near the intervention’s
target groups to make centres accessible. Each centre is equipped with a playroom for
children, a consultation room for parents, a kitchen and a bathroom with a washing machine.
Services are mostly provided in Sure Start Houses but events are also organised outside
these -for example in kindergartens, schools or other public places.
Regarding the potential to reduce inequalities in ECD, the participants explained that the
program was developed to support children and their families to reduce health, social and
education inequalities in the most deprived micro-regions in the country. It operates mainly in
settlements where early education services are not available, focusing especially on 0-3 year
olds. Many children are only enrolled for the compulsory 1 year pre-school program.
Sure Start was described by the respondents as a programme which addresses inequalities
in child development and health by providing high quality services to groups with little or no
access to these. The program is based on cooperation. Local social, healthcare, education,
child welfare institutions and services collaborate and efforts are made to inform the public
about the aim of the program encouraging all families-not only the most deprived-to
participate.
Staff mentioned having developed a mentor program. Mentors visit Sure Start centres every
month and provide supervision and consultation. Every centre adapts to local needs but high
quality is ensured, according to respondents by following an existing common framework
and values, training and regular supervision.
The program has a holistic and comprehensive approach, based on the child’s
developmental needs and rights. The centres involve parents as partners and encourage
them to discover and use their own resources and capabilities. The programme takes into
account the following areas of early childhood development: emotional, physical, cognitive
and social domains. It provides stimulation through play and other activities.
“The methodology is based on peer support and formal and informal learning. Both the
parents and children have the opportunity to meet and learn from each other” Sure Start
manager
Staff described the most important aims of the program regarding ECD and health and some
of its social determinants: providing early education opportunities to encourage cognitive
development and improved emotional wellbeing and reducing regional poverty, deprivation
and ethnic inequalities. By achieving this Sure Start staff aimed to improve life perspectives,
future opportunities and outcomes.
“The Hungarian adaptation of the Sure Start Houses were developed in order to support
children and their families to reduce health and social inequity in the most deprived
micro-regions in the country.” Sure Start manager

19
The services’ target groups, as described by the respondents, are mostly children age 0-3.
They also accommodate children up to 5 years of age to ensure their school readiness (in
Hungary this is the compulsory pre-school age 1 year prior to school. From September, 2015
it will be 3 years of age). Everyone from the local community can use the services but it
provides activities with a special focus on children from poorer, deprived families to prevent
developmental delay. Involvement of parents is a key point, the program is based on the
active involvement of parents to understand and contribute to the optimal development of
their children. As described by the staff, the programme provides support and information as
well. One of the basic values of the programme is to not exclude anyone, as described by
respondents. However, priority is given to children coming from deprived backgrounds.
The programme reached out to the most deprived by working closely with the local health
visitors, child welfare services, kindergarten and other institutions in the local community.
The interviewees explained that according to their experience, the program achieves
reaching those who would benefit from it most; however there is still not enough information.
In Budapest, in the 8th district, Sure Start centres are not able to accommodate for all the
families. However in the small villages they described cooperating with different
professionals in reaching out and felt they reached their target groups. The involvement of
Roma and non-Roma families in the same activity can be difficult and reaching the most
isolated groups was also described as difficult. Their service users are mostly Roma
population therefore, Sure Start managers try to employ Roma staff members as well.
“According to our experience the Program can reach those who would benefit from it in
most instances, however there is not enough information available.” Sure Start manager
Informants explained that the programme is assessed by measuring the development of
every child. An evaluation report is carried out every 6 months and shared with the parents.
In 2009, 2010, 2011 and 2013 studies on the outcomes of the programme were published by
the committee which was set up to evaluate it and in 2012 a civic report on children’s
chances was also published. According to the expert who designed the Hungarian
adaptation of the UK Sure Start Program the documents suggest that the programme is a
success and include information on the barriers and recommendations on how to overcome
these. There was a plan to conduct a longitudinal comparative study to evaluate the impact
of the regular attendance to Sure Start Houses comparing to children who were not taking
part in the program. However, the informants explained that the government elected in 2010
decided to cancel it and according to the respondent, it would have been extremely
important to demonstrate its usefulness as it would help to improve the services for families
and young children all over the country, similarly to the UK evaluations. The programme
manager interviewed explained that Sure Start undergoes an external evaluation every 2
years following a detailed indicator system. The evaluation assessed the socioeconomic
context of the children and their families as well as children’s development and success in
kindergarten and schools.
“Yes, documentation is used to follow and measure the development of every child. It is
filled out every half year and shared with the parents as well. These documents are
evidences of the program’s success.” Sure Start manager

20
With regards to the funding received by Sure Start, the respondents explained that during
the first 3 years the programme received EU funding; during this period The Szécsény
micro-regions received approximately 2 million Euros. During 2012 the situation was
described by the informants as unsettled and they looked for private donors. However, from
2013 onwards, Sure Start has been funded by the Hungarian government.
The respondents explained that when the programme was first implemented an essential
obstacle was the fear of lack of sustainability because the government’s commitment
towards funding the programme was unclear. However, Sure Start centres are now part of
the national inclusion and tackling child poverty program.
According to the interviewees, some parents attending the centre are apprehensive about
facing or being confronted by their own problems and fear being judged by others. They feel
they lack skills and might be humiliated or fear their children might be taken away. In
Hungary there is very little tradition of seeking help and accepting support as quite often
there is a judgemental negative approach towards it. In these cases the staff from Sure Start
access parents via friends, grandparents or other community members to help them gain
confidence in the programme.
Further barriers described by the interviewees referred to the high resource demand and to
the population´s needs in the micro-regions and explained that intersectoral professional
workshops were carried out every month to overcome these.
B: Sure Start Hungary focus groups with parents
During the group discussion, the families participating shared their feelings of helplessness
prior to the opening of the Sure Start House. They felt “alone” with their problems and
ignored by public services. Participants tried many possibilities in searching for an
appropriate place to spend quality time with their children and other mothers/parents.
The participants agreed on the important role of well-designed and properly managed
interventions but questioned the quality of the public services in their area. A detailed
discussion explaining how the Sure Start centre has changed their circumstances evolved
among parents as it has given them hope and opportunities in raising their children in a
better way. They referred specifically to the usefulness of the play group as well as having
access to the washing facilities, computers, child care and snacks provided for their children.
The friendly and supportive non-judgmental attitudes of Sure Start professionals were
mentioned on many occasions.
Parents agreed that in most cases school failure is a consequence of life circumstances
within the family and in the wider environment, stressing the importance of early childhood
development services. They also agreed on the importance of community support during
pregnancy and the first years of the child because mothers often feel left alone and isolated
during this period of time. Two mothers from the focus group who regularly visit the Sure
Start Centre explained that one of them has a child with special needs and is satisfied with

21
the skill and competence in development that the program offers. The other mother
described simply enjoying being part of a diverse group and helping other mothers.
Some of the parents had visited Sure Start Houses before but the majority felt that they were
not the target group of the service and that it was aimed at children belonging to “poor
families”.
Universal Health Visitor System
A: Individual interviews with health visitors
The respondents explained that in the more deprived and complex areas health visitors are
responsible for more than 400 children. The unemployment rate in these areas is two or
three times higher than the country average and approximately every third child lives in a
home where everyone is unemployed. Furthermore, the interviewees explained that
education outcomes are poor but community bonds are strong.
“The unemployment rate is two or sometimes three times higher than the country
average and around every third child is living in a family where no one has a job. The
education outcomes are poor. Community relations are strong.” Health visitor
Regarding the description of the service, the participants explained that it is a universal
programme providing home care for young children to promote prenatal health and the
healthy development of infants and toddlers as well as supporting and providing advice for
mothers. The health visitor´s principal aims are: prevention, early intervention and referral to
other services if needed. Ideally one health visitor carries out a follow-up of the child on a
long-term basis.
“Health visitation’s aims are: prevention, early intervention and referral to other services
if needed.” Health visitor
The respondents explained that as health visitors they offer advice and carry out consults,
counselling (breastfeeding, care of the infants and children, prevention of unwanted
pregnancy, recognition of child abuse and neglect, maternal depression, etc.), medical
examination of new-borns and toddlers, immunisation, compulsory childhood vaccination,
recognition of emotional or other type of abuses and neglect. From 2013 onwards, cervical
cancer screening has also been introduced.
Most of the work is carried out in the family home following an individual care plan which is
developed together with the parents. The respondents explained that the service also counts
with and outpatient clinic for families and health visitors also have regular visiting hours in
Sure Start centres. These visits-as described by the respondents-provide the opportunity to
visit more mothers and children together, travel less and reach more people, especially
those who are hard to reach. The health visitors interviewed also explained that they visited

22
kindergartens every 3 months in their district to assess the facilities, cleanliness, etc. and to
meet with the children in a group situation.
When responding to how the service addresses inequalities in ECD, the respondents
explained that the health visitors provide health and development services directly to family
homes. It aimes to promote the physical, mental and social well-being of families and their
children and help improve parenting abilities by assessing children’s needs and preventing
neglect and abuse.
The interviewees described providing a wide range of services for every mother and child,
depending on their needs. Families with higher needs receive specific interventions that
respondents described as having the potential to reduce inequalities in children. Health
visitors follow the development of the child ensuring their health by providing all the
necessary preventive measures. The respondents were of the opinion that early recognition
of special needs plays an important role in reducing inequalities.
Domains of child development
The home visitor´s programme was described by the respondents as a service which
focuses on all dimensions of child development.
“Home visitation includes all dimensions of child development: physical and emotional
as well. The recent requirements to detect and report child abuse and some forms of
neglect is causing a lot of concerns as our training has not been focusing on this areas
and communication with the families is not always easy.” Health visitor
Respondents described it as a universal service covering the entire country. Service users
are expecting women, mothers with young children and children aged 0-6 or older if they
have a disability or special needs. The respondents felt that the service reaches the intended
users; however homeless or non-registered families, among others, are hard to reach.
“It is a universal service covering the entire country. Service users are expecting
women, mothers with young children, infants, toddlers, children aged between 0-6 and
older children with disabilities or special needs.” Health visitor
The respondents stated having no information on outcomes, but local services have
collected basic data on the interventions (number of contacts, number and age of
beneficiaries, services utilised, etc.). There is a periodical published by the Association of
Health Visitors (MAVE) and many unpublished thesis have been written at master’s and PhD
levels so far but the respondents are not aware of any research on an overall evaluation.
The service is funded by the central government´s budget and the local governments. The
interviewees explained that the health visitor’s salary is very low despite the fact that they
have received 4 years of training in college.

23
Barriers encountered when implementing the intervention or service
The respondents referred to the health visitor´s low salaries and the fact that caseloads are
high and that the administrative paperwork takes longer than the visits themselves. An
additional barrier is that a growing number of cases are being taken on by GPs with no
specialised training on children’s health. In many instances the health visitors interviewed felt
they did not have sufficient information regarding some of the children. For example parents
may not have immunisation or previous hospitalisation records which makes providing health
care more difficult for the professionals delivering the service.
“The caseloads are high and the administration of the visits takes longer time than the
visits themselves.” Health visitor
The health visitors interviewed referred to the barriers sometimes encountered when visiting
wealthy and/or highly educated families because they sometimes do not agree with the
importance of the work carried out by the health visitors and/or they may sometimes have
different views on health care. They sometimes prefer different approaches such as
alternative medicine, homeopathy or not vaccinating their children, for example. The
respondents explained that some parents feel they know more about their children’s health
than the professionals who visit. However, the interviewees explained that some health
visitors still represent old fashioned principles or do not have the required communication
skills and can be judgemental. Establishing trusting relationships is also described as difficult
by the interviewees. They explained that in order to do so, they identify the key carer within
the family and earn their trust. Staff found it difficult to work with some families because they
were wary of professionals and workers from the public sphere.
“People on the other hand are often irritated, angry and sometimes aggressive many
of us are scared, try to avoid any conflict. They blame us for the lack of services, free
medication, etc. it is getting very hard.” Health visitor
B: Focus group with Universal Health Visitor System and Sure Start parents
Due to the very limited opportunities and the lack of tradition of community based self-help or
any kind of volunteering, most mothers struggle alone according to respondents. There is a
widespread belief in Hungary that mothers should stay at home with their children until at
they are at least 3 years of age.
Most parents in the group were highly satisfied with the services offered by their health
visitors. They described having a trusting and close relationship with their health visitors.
Parents were also grateful because visitors could be reached any time when they needed
advice. However some parents had had negative experiences in the past with health visitors.
For example, they did not offer the help they needed, only carried out the administrative
paperwork during visits or were not approachable.

24
Barriers
Some participants expressed feeling reticent about talking to professionals employed by the
government and letting them intervene in their private life. They felt strongly that it is a
patronising program threatening the autonomy of their families while accepting that many
families need it if carried out accordingly. Some of the parents felt it did not meet their
expectations and were not satisfied with their health visitor’s attitudes. Some parents felt it
was an unnecessary intervention as when parents need help they prefer to ask their own
families, experienced women in their community, friends, or a professional they trust. Books
and the internet are also other sources of information parents described as useful. During
the discussion some participants realised that they had the same health visitor but had
different experiences with him/her. It was commonly acknowledged that there are many
controversial discussions regarding child care and many different messages on the “best”
ways of taking good care of children. They were of the opinion that health visitors lack
information or are often too busy and do not have time to listen to and discuss the more
complex issues. All the participants agreed that the role of the paediatrician is crucial.
Theotokos Centre
A: Individual interviews with mothers
The mothers described coming from very deprived backgrounds. They live/d in shelters or
on the street and have little or no family support and have chronic illnesses. They have
suffered abuse from family member s and/or their husbands. Most did not have a stable job,
did not have sufficient income and could not afford accommodation for their family. Maternal
grandparents were described as being involved in raising the children and offering economic
and emotional support to families.
The mothers explained that the Centre finances their children’s kindergarten which in their
opinion contributes to their education. They expressed liking the centre and its kind staff and
felt the children enjoyed attending it.
Some were referred to the Theotokos Centre by child protection services and other similar
social services.
B: Theotokos Centre individual interviews with staff
According to employees’ responses, in most cases, beneficiaries are sent to the centre by
the General Department of Social Assistance and Child Protection. Most of the mothers
grew up in a children´s shelter run by social services within Cluj-Napoca City Hall and by
other social service providers.
“Families who have high socio-economic difficulties, which face a very strong
marginalization who are extremely disadvantaged in several aspects.”

25
Charities and similar organisations refer single mothers and children, because according to
respondents, there is only one centre in the city which can only accommodate mothers with
babies under 6 months. Some of the families came to the centre of their own accord. In the
autumn of 2013 a vast action for identifying children who were not enrolled in the state
education system was carried out and according to respondents, some of these children now
benefit from its services. However, there are situations where need exceeds the capacity of
the centre, especially the day-care centre which is limited to ten children. Due to limited
space and resources the day-care centre can only accept 30% of the cases referred to them.
The eligible families were registered on a "waiting list" or sign-posted to other institutions that
provide support or food supplies during difficult moments. There are specific working tools
(individualised protection plan) and ongoing activities with specific goals and aims (each
child has a weekly activity sheet). However, there is a certain focus on involving and
empowering parents regarding their children.
“Project objectives are: (1) improving the quality of life for 30 children from single
parent families aged 0-6 years who are at risk of maternal abandonment; (2)
development of employability skills in society for 55 members of single-parent
families….” Head of the Theotokos centre
Respondents explained that the day centre for children offers full free nursery services from
6am to 6pm, 5 days a week. The program was designed to hold a maximum of 10 children,
and the centre works mostly at its maximum capacity. Children benefit from three meals in
the centre; they can sleep in comfortable and age appropriate beds and play with stimulating
toys. A trained person supervises children and guides their play. The staff explained that
they know how to comfort children who often seem anxious and frustrated. The centre also
offers counselling and support for parents (usually mothers). As described by the respondent
workers, the activities are designed to ensure the preservation of the family unit, to develop
the parental capacities of the mothers, and to help them overcome critical situations which
could cause the child's separation from the family. The program reinforces mother’s
attachment to their children, considered very important during the first three years of their
lives. The “support group" activity takes place weekly and a large number of beneficiaries
are encouraged to take part. A fixed programme of meetings with mothers and a set of
topics to be discussed at each meeting are established. The meetings are supervised by the
project coordinator, the psychologist and the social worker. Sometimes, depending on the
themes of the topics chosen, the doctor who monitors the health of children, or the priest
responsible for spiritual counselling are invited to attend the meetings.
“The Centre wasn’t built by a particular model, the needs and problems of the
community have called for the establishment of the Centre and the development
of related services.” Head of the Theotokos centre
Employees’ feedback underlined the importance of services provided in order to help
reducing potential inequalities in early development among children who come from
disadvantaged backgrounds by offering them access to quality early education. The
employees explained that children are cognitively stimulated in the centre during the 10-12
hours spent with trained staff; their health is maintained at an optimum level; they receive
care, food, attention and everything they need. Moreover, parents and caretakers are

26
involved in various activities that aim at necessary skills for social and professional
integration and leading a responsible, self-supporting life. According to the employees, the
intervention is not built on any particular model but it leads to positive results.
“The center has effective tools…responsibility for ensuring the growth and
development of children rests primarily parents, they had a duty to exercise their
rights and fulfill their obligations to the child taking into account the interests of its
priority.” Head of the Theotokos centre
The employees explained that in terms of social work, a personal case chart is completed
with information regarding the mother, the assistance agreement between the two parties, a
personalized intervention plan, depending on the identified issues and needs, a
psychological evaluation sheet, a counselling individualised plan, an appointments’ diary -
recording progress-, and a family case study. Regarding counselling and supporting the
child, an initial assessment is carried out with several tests; the intervention plan is devised,
as well as a monthly assessment plan, activities chart, and the medical report. After the
initial assessment, the case monitoring starts, as well as periodic reassessment ending with
the final evaluation. All these tools offer relevant information about the family situation from
all points of view, about the development of the child and the mother or their capacities
performing different tasks and duties.
“The headquarters are located in an easily accessible by public transport and as shown
is located in a quiet area.” Head of the Theotokos centre
Domains of child development
The respondent referred to the trained personnel hired in order to take into account various
dimensions of child development (for example, early childhood cognitive development). The
team is multidisciplinary, composed by a coordinator, a manager, a psychologist, a social
worker, a supervisor (part-time), four early childhood educators, a doctor (part-time) and a
priest. There is an emphasis on verbal development: verbalizing activities and storytelling.
Singing and music is part of the program, as well as movement, coordination and outdoor
free play.
There are different types of internal evaluations such as weekly meetings with team
members to monitor each case to see whether the objectives have been achieved in the
Individualised Protection Plan, for example. The development of children is also monitored,
by the psychologist and the speech therapist and elaborate individual intervention plans if
necessary. According to some employees the children who did not show progress were
often not attending the programme regularly. During the 9 years of functioning, the program
has assisted more than 200 mothers and their children. There is always a waiting list for the
available places, and selection is made according to the risks faced by mothers.
The main sources of funding were: the state, the City Council of Cluj-Napoca, the U.S.
Orthodox Christian Mission Center, campaigns performed in schools, donations from
individuals and businesses. In addition to various internal and external sponsors, campaigns
and self-financing was achieved by small amounts of money from the sale of handmade
items created by our studio.
“But to have it exactly as you see it now major investment was essential to
Orthodox Christian Missionary Center of America.” Social worker

27
Barriers encountered when delivering the service
Employees mentioned an obstacle in the intervention being the limited space capacity
because it cannot provide services to new beneficiaries or to a larger number of children. In
the beginning the centre was unknown to the business community or other potential funders
however, at present a large part of their work is supported by the goodwill of many people
from the community of Cluj. The employees also referred to some initial reluctance of the
mothers to follow the advice provided, mainly due to the change of lifestyle habits. However,
previous experience of the staff working in the centre helped them to successfully overcome
this difficulty and build trusting relationships with the mothers.
C: Focus group with mothers attending the Theotokos centre
Socioeconomic background of the beneficiaries
Some of the mothers explained that they lived in an Emergency Center and some had also
grown up in a children’s home. Most had to live in centres or shelters because they did not
have sufficient money to pay the rent. They have little or no support from their families or
from farther of the child. Most of the mothers had their children at age 21. They described
not having very trustworthy relationships with the children’s parents and not relying on them
as carers. Mothers who lived with their family described living in overcrowded conditions and
having to look after other sick members of the family.
“I got a degree, but I could not work in that direction because the girl was too small
and I had nobody to stay with her. Now I work as an assistant cook at an organization
-Prison Fellowship.” Theotokos centre mother
“Me and my older sister are the sole support of the family and for me the biggest
support was and remains my mother, even if she's so sick.” Theotokos centre mother
Mothers expressed liking the building but were concerned about the lack of space and other
families not being able to access the centre’s services. Mothers explained not paying any
fees and not knowing how the centre is funded. Some mothers did explain having some
knowledge on items being made by the staff and sold during festivities to raise money.
“Now, we found an organization, which pays our rent and so we live all together in a
pretty house.” Theotokos centre mother
Mothers referred to their children receiving an education and the centre being in good
conditions. One of the mothers explained seeing her daughter learning to count and identify
colours and singing songs. The mother explained that her daughter was not able to attend
for a year due to the mother’s absence from the country and during this period the daughter
forgot what she had learned and her progress stagnated. Other mothers highlighted the
good hygienic conditions of the premises and that staff looked after the children’s overall
wellbeing.
“A. tells me and shows me a lot of things. In the Center, he learned a lot of good
things; he knows a lot of words and many different songs. I like to go out and play
with my kids in the park where we sing and we have fun.” Theotokos centre mother

28
“My children are well and I love them very much. With my little baby, I was coming
here to the Center since he had 3-4 months .... I bring him every day because I
learned the way on my own.”
Some mothers described being referred to the Theotokos centre by child protection services.
The centre helped mothers by providing financial resources and paying for their children’s
preschool fees.
“Yes, the Center helps us as they could... First, financial and then with a kind word,
an advice and so on. Also we received food once a month and I don’t know what I
would have done without their help ...” Theotokos centre mother
One mother explained having attended a meeting with attendants from the finance
department and felt that they were optimistic about the centre’s achievements.
“My youngest daughter came here where she is very well. The children are clean,
they receive attention, somebody take care of them and here are specialized
personnel which deal with them.” Theotokos centre mother
Mothers referred to the limited space and other families not being able to make use of the
services. Most of the mothers explained that they used tram season passes to reach the
centre but could not bring some of their children along to some of the meetings as they did
not have enough money to buy their ticket. In addition children were still accepted at the
centre even if they were ill and this made some of the other children ill as well.
“But sometimes he gets sick because there are a lot of children in the same place and
take the ill each other. Three weeks ago he was very ill with bronchitis, conjunctivitis and
I took him home.” Theotokos centre mother

29
Discussion
Most programmes were delivered in areas with low levels of service provision, the exception
to this was Netzwerk Familie. The majority of families and children were from deprived
backgrounds. Programmes that were not universal reached beneficiaries using a variety of
methods. These included contact in hospitals after delivery, through social services,
community groups and relatives. Only the universal health visitor programme delivered in
Hungary began in the ante-natal period. The objectives of the programmes were to enhance
children’s health and development. These were delivered by staff members from the health,
psychology and social sectors. Some–Toybox, Sure Start and the Theotokos centre-
provided activities to stimulate children’s learning through structured play and provided
support and assistance for parents. In the three programmes the parents were actively
involved in activities and respondents referred to long-lasting trust based relationships
between staff and parents as one of the basis for the success of these programmes. Staff
and users generally gave very similar accounts of the intervention through their experiences,
and parents expressed a high level of satisfaction. The exception to this was the health
visitor programme where the two groups of informants put forward a slightly different view
regarding the main barriers to implementation. While both groups agreed that limited
available resources and space were a barrier, staff identified the reluctance of parents to
attend some of the services and parents highlighted a bureaucratic approach by staff. The
available evaluations were based on monitoring indicators and measuring output and
process assessments. No long term evaluation or comparison with a control group had been
carried out.
Representativeness of case studies
This report illustrates early years initiatives delivered in Romania, Hungary, Austria and in
the UK. Ensuring a sufficient range of countries to reflect the different contexts in Europe
was one of the selection criteria for interventions included in this report. To reflect evidence
of early years interventions carried out in countries which were not represented in the
systematic review of early years interventions aimed at reducing inequalities (19).
Respondents from these countries described interventions being delivered within a context
of insufficient children’s social and health service provision. The interventions were
delivered, in part, to bridge the gap of insufficient services to families mostly from deprived
backgrounds. Programmes were open to the community; however, activities had a special
focus on children and families with disadvantages, with the exception of the universal health
visitor programme, which targeted the entire population. Similarly the systematic review
carried out within the ECD strand of Drivers (19), found that the majority of interventions
identified were targeted at children living in deprived areas. The interventions were aimed at
reducing social inequalities in children’s health and development but not at levelling the
social gradient in health (20).
Common findings
The objectives of the programmes selected for this report were to enhance children’s
development and health, to provide a space for parents and children and give parents
support and assistance and delivering activities and structured play. The programmes were

30
identified from within a sample of interventions provided by third party organisations
collaborating with the Drivers project and do not necessarily represent all the programmes
being delivered across Europe. Nevertheless, the results show similarities with the main
findings in the systematic review of interventions (19). Those that were most effective aimed
to improve parenting capacities and some had additional components such as: day-care
provision, improving housing conditions and speech or psychological therapies. Programmes
offered intensive support, health information and home visits using a psycho-educational
approach and aimed at developing parent’s skills. The interventions identified in this study
also aimed to provide access to quality early education to reduce potential inequalities
during the early development of children, especially for those who come from disadvantaged
backgrounds. The evidence from the review also showed that programmes which included
prenatal visits had better outcomes than those starting after birth and those beginning during
the first stages of life in turn had more favourable results than those beginning when the
child was older (19). However, among the case studies described in this report, only the
health visitor programme provided prenatal care.
Targeting capacity building
It was mentioned by the majority of staff that delivering an intervention -aimed at young
children and their parents- effectively, entails recognising the knowledge and capacities of
parents. The programmes were aimed at strengthening parenting abilities to assist in their
children’s learning and development and most adapted to and understood the families’
circumstances. Interventions involved parents through play and were flexible to ensure
parents’ participation. Programmes were delivered by staff from different disciplines, some
such as Family Network were provided by a network of professionals. Staff saw providing a
comprehensive range of services with the potential to reduce inequalities in children -to
every mother and child, important. Similarly, other studies illustrated how parenting activities
across income groups and the social gradient (4) fostered through ECD programmes were
not limited to cognitive gains, but also included physical, social, and emotional gains, all of
which are determinants of health over the life course (21). Further evidence also described
that parenting programmes offer valuable opportunities to positively influence children’s
health and create resilience (12). However, while focusing on parenting is important, it is
also necessary to address the conditions of daily life which make positive parenting difficult.
This requires policies aimed at children through an explicit, multi-dimensional and integrated
strategy (22) and investment in reducing child poverty and improved living conditions (23).
An important aspect of early years programmes is the quality of relationships between the
deliverer and the recipient as well as ensuring that the recipients who meet the eligibility
criteria receive programmes relevant to their needs. Evidence from a study reviewing the
literature on inequalities in ECD and health, which forms part of the Drivers project, showed
that most social factors, at both the neighbourhood and household levels, influenced early
childhood health and development extending across a wide range of adverse health and
developmental outcomes in early life (24).
Involving parents
Aims such as encouraging and supporting parents/families to become involved in community
activities by engaging with them through children’s programmes were also important

31
components in most interventions. Similarly, LicketyLeap - an interactive theatre play for
children involving action learning, where children participated in the performance - was
designed to encourage children to develop new skills and learn through multiple reactions to
imaginary situations (25). The intervention, delivered by the early years service Licketyspit,
reinforced learning experience and aimed to build on their confidence by integrating Applied
Theatre practices (26), fostering imaginative play among children and engaging with their
significant adults. The objectives of the intervention were to fortify parent and child
attachment, confidence, self-esteem and children’s capacity to flourish. LicketyLeap was
delivered in Scotland, in deprived areas within North/South Edinburgh, East Lothian,
North/South Glasgow and Fife. It engaged with hard to reach families delivering two half-day
sessions led by two specialist actor pedagogues. Target groups were children 3-5 years old.
Parents/carers attended the second half of the follow up session to hear about the project
and see some live performances performed by children. The programme had been delivered
to 29 nurseries attended by 1510 children in multiply deprived areas. A mixed methods
evaluation showed an increase in children’s confidence, improve their social skills their
resilience and ability to problem solve (4, 5).
Barriers in implementing interventions
Beneficiaries referred to fear of being judged as a barrier as well as some reluctance
towards the programmes. In addition, insufficient capacity and resources limited the number
of children, families and /or mother attending the centres. Funding was described as a very
important obstacle by staff working in programmes which were not funded by the
government. Stigmatisation of users and/or showing some mistrust towards service
providers and programmes may be customary within a prevailing culture of low levels of
service provision. Furthermore, the gap in service provision was accompanied in some areas
by a reduced use of existing infrastructures and lack of intersectoral collaboration.
Other interventions examined
The Ruchazie Family Centre and North Ayrshire early years programme in Scotland are
further examples of interventions providing support and activities for parents and children.
The Ruchazie Centre delivers integrated early childhood education and care, outreach
support for parents and direct work with families and children. It encourages mutual support
among families and develops a sense of cohesion in the community. Emotional support is
provided in a safe environment by qualified staff. An independent evaluation of the work of
the Centre was carried out in 2006 (27). Findings indicated that while 97 percent of children
were assessed as receiving poor parenting on referral, by age three, 77 percent ( 17 out of
22) were no longer considered to be at risk and all children had improved relationships and
attachment with their parents despite 67 percent having poor attachment at the time of
referral.
The North Ayrshire Council piloted the inclusion of at risk two year olds in their pre-school
education provision, normally available to three and four year olds. The programme included
flexible attendance patterns and a curricular focus on ‘positive learning experiences’. These
positive experiences were provided by building relationships with children and parents,
supporting children’s sensory experiences, developing their language and creativity,

32
promoting their physical development and encouraging their enjoyment of their environment.
An evaluation of the programme was carried out during the second year of the pilot between
August 2007 and June 2008 (28). Parents of vulnerable children in the extended pilot
programme showed improved parenting capacity compared to comparison group parents.
Children in the pilot programme showed improved developmental outcomes but their
progress was not significantly different from that of comparison group children. Staff reported
new learning on their part that would inform future practice with pre-school children.
Comparison with other analysis
An analysis of inequalities across cohorts from 12 European countries, which also forms part
of the Drivers project (8), illustrated that poor health is greater amongst children of mothers
with low education. Therefore interrupting intergenerational transmission of inequalities is an
important consideration (5). Longitudinal birth cohort studies, such as these, provide data
which can help monitor health inequalities and the impact of early years interventions. A
further example of a cohort study is the GUS longitudinal birth cohort commissioned by the
Scottish Government in 2003 which collected data from three child cohorts and included
aproximately 14,000 children. This longitudinal research project aimed at tracking the lives of
a cohort of Scottish children from the early years, through childhood and into adulthood.
Focusing initially on a cohort of 5,217 children aged 0-1 years old (birth cohort) and a cohort
of 2,859 children aged 2-3 years old (child cohort), the first wave of fieldwork began in April
2005. Among the 1,800 variables collected, the following questions and measurements were
included: the children's birth weight, their experience of long-term health problems,
accidents, poor psychosocial health, reported behaviour difficulties and problems with
cognitive or language development. The risk factors for poor health were: maternal smoking,
maternal health, children's physical activity levels and their diet (including whether they were
breastfed). These outcomes and risk factors were explored in a study by the Scottish
Government in relation to area deprivation, household income, and household socio-
economic classification. They showed that children whose mothers smoked at some point in
their early years, most were exposed to this on a prolonged rather than temporary basis. The
more disadvantaged households faced a double burden in their experience of health
inequalities as both the children and adults within them were at greater risk of negative
outcomes (30).
Comparison with programmes outside Europe
This case studies report focuses on interventions delivered within Europe. In a like manner,
in the early years Drivers systematic review (18), all but 1 of the interventions-delivered in
Sweden-were carried out in the United Kingdom and the Republic of Ireland. However,
examples of early years programmes outside Europe have been well documented: “The
Perry Preschool Project” delivered during 1962–1967 and the “High/Scope Preschool
Curriculum Study” (1967–1970) which showed positive outcomes for test scores, high school
completion, lower arrests and criminality, teenage pregnancies and higher home
ownerships. The “Carolina Abecedarian Project” (1972–1985) and the “Syracuse Family
Development Research Program” (1969–1975) had an impact on improving development
and intellectual quotient scores (6, 31). The Nurse Partnership, also, has shown long-term
beneficial effects in the USA. It was evaluated by three RCTs and children in the intervention

33
group showed higher reading and mathematics tests scores. Long term evaluations showed
children had fewer sexual partners, less smoking and drinking and ingestion of dangerous
substances. Injuries and abuse were also reduced as was criminality during later years (32).
“Sure Start” Australia (33) showed very little detectable difference between the intervention
and Start-to-be communities. “Head Start” in the USA (34) improved conduct problems and
noncompliance (35, 36).
Strengths and limitations of this study
The study had several limitations, the interviews and case studies were performed by third
parties in each country. This may have contributed to differences in carrying out of interviews
and focus groups to differ across interventions. The fact that third parties performed the
interviews and focus groups was also a strength as these were carried out in their native
language and in the majority of instances they were involved in delivering the intervention or
had close contact with managers and therefore there was a previously established
trustworthy relationship. Third parties provided University College London with summaries of
the notes taken and recordings of sessions. These differed in length and detail and were at
different levels of interpretation. The limitations however were mitigated by the fact that UCL
provided a common template and guide for third parties to carry out the case studies. These
included guidance on the methods to be used for the individual interviews, focus groups and
on providing socioeconomic indicators. There was no consistency in the types of
assessment or evaluation carried out in the case studies. Informants described periodic
monitoring, assessing children’s performance or collecting data on the delivery of
interventions, however, there was a lack of quantifiable data to assess whether programmes
had a long-term impact on health and development. The interventions selected in the Drivers
early years systematic review (8) had undergone an external formal evaluation and their
main findings where that interventions with better outcomes and higher level of evidence
combined workshops and educational programmes for both parents and children beginning
during early pregnancy and included home visits by specialised staff. In the future,
evaluation of early years programmes would allow comparison of the outcomes of
programmes delivered in families’ homes or centres. For example, the systematic review on
early years interventions found that interventions with better outcomes combined both.

34
CONCLUSIONS AND RECOMMENDATIONS
Conclusions
Establishing long lasting trust based relationships was described as an enabler in the
delivery of programmes and services, especially to socially isolated or hard to reach families
and children. Programmes described as being successful, in providing support and building
on parent’s capacities, delivered flexible services with activities carried out by
multidisciplinary teams. Staff stressed the importance of adapting to and understanding the
families’ circumstances and involving parents as it contributed towards empowering parents
and developing their educational skills. According to respondents, this had a positive effect
on children. By providing a comprehensive network of professionals across disciplines,
programmes aimed to cover the additional needs not met by standard ECD social and health
service provision in their areas.

35
Recommendations
1. It is important to provide access to a comprehensive range of quality early year
services to reduce inequalities during the early development of children, especially
for those who come from disadvantaged backgrounds.
2. Services should be tailored to social and economic need.
3. It is important to recognise the knowledge and capacities of parents if interventions
aimed at young children and their parents are to be delivered effectively.
4. To ensure that parents have an active involvement in early years programmes, they
should receive support and information to understand and contribute to the optimal
development of their children.
5. Parents should be empowered to develop their own educational skills thus
strengthening their ability to assist in their children’s learning and development.
6. Existing ECD institutions and structures should be strengthened to promote cross-
sector working between the social, education and health sectors.
7. The recognition, representation and funding of ECD in all areas of work and policy
should be enhanced through high-level leadership. This includes promoting support
for children who are deprived or vulnerable.
8. Programmes delivered in families’ homes and in accessible centres should be
evaluated so as to compare outcomes when using one or other of these settings or a
combination of the two.

Early child development: Report on case studies

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